Asthma outcomes study focuses on function

Self-management program improves productivity

Looking for a patient education program that really works? You might consider one developed by Glaxo Wellcome Care Management in Research Triangle Park, NC. Called the Asthma Self-Management Program (ASMP), the 12-month outcomes study showed participants improved their productivity and general well-being while significantly reducing their use of the health care system.

Comprised of eight hour-long asthma education sessions, ASMP showed a return of $1.85 for every dollar invested after 12 months, not counting indirect cost savings due to reduced absenteeism and increased productivity. (For specific outcomes data, see graphs of results, pp. 22, 23.)

"We know the program works. What we’re changing now is the way we recruit and retain patients," says Mark Santry, director of the respiratory management group for Glaxo Wellcome Care Management. "We commissioned research to help us understand what motivates people to participate in disease management programs and incorporated what we learned into our recruiting materials and methods."

Tailoring material for target group

The new materials are tailored to the program’s target audience, he notes. "We’ve identified people as high utilizers’ or light utilizers’ based on their use of the health care system. The new recruiting messages are targeted to appeal to potential participants based on their use of the health care system."

Glaxo Wellcome has also changed the methods it uses to reach potential ASMP participants. "We’ve moved away from print and video messages to a telephone outreach approach," he says.

"We use both live and passive outreach," he adds, explaining that "passive outreach" includes providing a toll-free number participants can call for more information about ASMP.

Most of the evidence demonstrating this new, more-tailored approach is working has been anecdotal, notes Santry. "We think the impact has been significant and will continue to show increases in participant recruitment and retention."

Glaxo Wellcome also applies a tailored approach to the outcomes reports it prepares for its customers.

"If I’m an employer, I want to hear about productivity and absenteeism, not just health care utilization. We’ve employed a number of instruments so that we can provide a wide range of outcome variables that apply to most of the customers we serve," he explains.

In addition to utilization data, Glaxo Wellcome measures SF-36 results for each participant and a functional status instrument that measures improvements in productivity. Outcomes for each participant are measured at these five points:

- prior to the participant’s first ASMP class;
- following the last ASMP class;
- at three months after completing the class;
- at six months;
- at 12 months.

"We tailor our outcomes presentations based on our preliminary implementation meeting with the clients. Maybe all they want to hear is how many hospital admissions there have been," he says. "If that’s the case, that’s what we report back. We let the customers dictate the level of detail based on internal needs, but the data are there if they want it."

Glaxo Wellcome also provides dedicated Web sites so customers can access data at any time. "The Web site is maintained by a data warehousing organization. Glaxo Wellcome doesn’t have access to it. We only see aggregate reports," explains Santry.

Customers can visit the Web site and select the report they want to view from a table of contents. "They can get on the Web and see that John Doe attended ASMP classes one, two, five, and six. They can check John Doe’s utilization. That level of detail is available if the customer wants it," he says.

The ASMP includes eight weekly education sessions using a behavioral modification support group model. It was designed to go beyond looking at just utilization to include productivity and the ability to perform activities of daily living. The program is taught by nurses, case managers, pharmacists, and respiratory therapists. It includes sessions on the following topics:

- principles of asthma management;
- nature of asthma medications;
- attack prevention and management;
- problem solving;
- relapse prevention;
- communication with health care providers.

Patients in the ASMP complete a questionnaire during the first weekly session for baseline data prior to any asthma education. In addition to the questionnaire completed in class, patients are given a questionnaire on medical history and previous health care utilization to take home and return at the next class session. (See Glaxo’s patients’ questionnaire findings, below.)

Patients complete the same questionnaire at the last eight-week session. "We then begin following patients quarterly from the date of their last class," says Deborah O. Lucas, MPH, manager of clinical economics and outcomes assessment for Glaxo.

Three- and six-month follow-up surveys are conducted by an interactive voice response (IVR) system, she says. "However, we contract with a third-party data vendor to contact patients who don’t respond to the IVR. We have an overall response rate of 90%," she says.

In addition, Glaxo Wellcome mails patients questionnaires at 12 months. "We also use the third-party vendor to contact patients by phone who didn’t mail back their questionnaires," says Lucas.

Glaxo considers its three-, six-, and 12-month follow-up contacts part of the intervention. Follow-up questionnaires are as much for learning re-enforcement as for data collection. If patients are asked if they are using their metered dose inhaler or keeping a diary of asthma triggers, the program administrators say the mere asking will serve as a trigger for renewed positive behaviors.

Glaxo Wellcome relies on standardized, validated outcomes measurement tools, which allow disease management programs to compare their outcomes to those of other programs.

The next issue Glaxo Wellcome hopes to measure is whether self-confidence is a strong predictor of positive outcomes in asthma management, says Lucas.

"We have built the whole concept of self-confidence into the program. We feel strongly that if patients believe they know how to manage their asthma it will reduce serious complications and improve outcomes," she says.

"We don’t have any data for that yet, but we’ve designed the instruments to measure them and plan to capture that data in the future," Lucas explains.


Asthma Self-Management Program Spring 1996 Program Findings

Questions
Baseline
(n=63)
3-month 
(n=31)
6-month 
(n=62)

How often do asthma episodes wake you up at night?
Never
27.0
77.4
41.7
Less than once a week
52.4
19.4
43.3
1-4 nights a week
7.9
3.2
13.3
5 or more nights a week
6.3
0.0
1.7
Usually more than once a night
6.3
0.0
0.0

In the past 4 weeks, did your asthma limit your physicalactivities?
Not at all
30.2
58.1
52.5
Somewhat
42.9
41.9
37.5
A lot
26.9
0.0
9.8

In the past 4 weeks, did your asthma cause emotional problems (such as feeling anxious, depressed, or irritable)?
Not at all
42.9
90.3
75.0
Somewhat
46.0
9.7
18.3
A lot
11.1
0.0
6.7

In the past 4 weeks, did your asthma cause you difficulty in doing your daily work, both inside and outside the house?
Not at all
31.7
58.1
62.3
Somewhat
57.2
41.9
29.5
A lot
11.1
0.0
8.2

In the past 4 weeks, how much did your asthma interfere with your normal social activities with other people?
Not at all
46.0
67.7
65.0
Somewhat
46.1
32.3
25
A lot
8.0
0.0
10.0

In the past 4 weeks, how much time have you missed from, work, schoolor your usual activities because of your asthma?
Did not miss any
73.0
83.9
80.3
1 day or less
0.0
12.9
13.1
More than 1 day but less than 1 week
25.4
3.2
16.6
1 to 2 weeks
1.6
0.0
0.0

Source for both charts: Glaxo Wellcome Care Management Research Triangle Park NC.